PEDIATRIC EMERGENCIES. Pediatric Emergencies Basic Approach to Pediatric EmergenciesBasic Approach...

PEDIATRIC EMERGENCIES

Pediatric Emergencies

• Basic Approach to Pediatric EmergenciesBasic Approach to Pediatric Emergencies– Approaches to patient vary with age and nature Approaches to patient vary with age and nature

of incidentof incident– Practice quick and specific questioning of the Practice quick and specific questioning of the

childchild– Key on your visual assessmentKey on your visual assessment– Begin your exam without instrumentsBegin your exam without instruments– Approach the child slowly and gentlyApproach the child slowly and gently

Pediatric Emergencies

• Basic Approach (Basic Approach (cont..cont..))– Do not separate the child from the mother Do not separate the child from the mother

unnecessarilyunnecessarily– Be honest and allow the child to determine the Be honest and allow the child to determine the

order of the examorder of the exam– Avoid touching painful areas until the child’s Avoid touching painful areas until the child’s

confidence has been gainedconfidence has been gained

Pediatric Emergencies• Child’s response to emergenciesChild’s response to emergencies

– Primary response is fearPrimary response is fear• Fear of being separated from parentsFear of being separated from parents• Fear of being removed from homeFear of being removed from home• Fear of being hurtFear of being hurt• Fear of mutilationFear of mutilation• Fear of the unknownFear of the unknown

– Combat the fear with calm, honest approachCombat the fear with calm, honest approach• Be honest - tell them it will hurt if it willBe honest - tell them it will hurt if it will• Use approach languageUse approach language

Development Stages -Keys to Assessment

• Neonatal stage - birth to 1 monthNeonatal stage - birth to 1 month– Congenital problems and other illnesses often n Congenital problems and other illnesses often n

notednoted– Personality development beginsPersonality development begins– Stares at faces and smilesStares at faces and smiles– Easily comforted by mother and sometimes fatherEasily comforted by mother and sometimes father– Rarely febrile, but if so, be cautious of meningitisRarely febrile, but if so, be cautious of meningitis


• Approach to NeonatesApproach to Neonates– Keep child warmKeep child warm

– Observe skin color, tone and respiratory activityObserve skin color, tone and respiratory activity

– Absence of tears when crying indicates dehydrationAbsence of tears when crying indicates dehydration

– Auscultate the lungs early when child is quietAuscultate the lungs early when child is quiet

– Have the child suck on a pacifierHave the child suck on a pacifier

– Have child remain on the mother’s lapHave child remain on the mother’s lap


• Ages 1-5 months - CharacteristicsAges 1-5 months - Characteristics– Birth weight doublesBirth weight doubles– Can follow movements with their eyesCan follow movements with their eyes– Muscle control developsMuscle control develops– History must be obtained from parentsHistory must be obtained from parents

• ApproachApproach– Keep child warm and comfortableKeep child warm and comfortable– Have child remain in mother’s lapHave child remain in mother’s lap– Use a pacifier or a bottleUse a pacifier or a bottle


• Ages 1-5 months - Common problemsAges 1-5 months - Common problems– SIDS SIDS – Vomiting and diarrhea/dehydrationVomiting and diarrhea/dehydration– MeningitisMeningitis– Child abuseChild abuse– Household accidentsHousehold accidents


• Ages 6-2 months - CharacteristicsAges 6-2 months - Characteristics– Ability to stand or walk with assistanceAbility to stand or walk with assistance– Very active and explore the world with their Very active and explore the world with their

mouthsmouths– Stranger anxietyStranger anxiety– Do not like lying supineDo not like lying supine– Cling to their mothersCling to their mothers


• Ages 6-12 months - Common problemsAges 6-12 months - Common problems– Febrile seizuresFebrile seizures– Vomiting and diarrhea/dehydrationVomiting and diarrhea/dehydration– Bronchiolitis or croupBronchiolitis or croup– Car accidents and fallsCar accidents and falls– Child abuseChild abuse– Ingestions and foreign body obstructionsIngestions and foreign body obstructions– MeningitisMeningitis


• Ages 6-12 months - ApproachAges 6-12 months - Approach– Examine the child in the mothers lapExamine the child in the mothers lap– Progress from toe to headProgress from toe to head– Allow the child to get used to youAllow the child to get used to you


• Ages 1-3 years - CharacteristicsAges 1-3 years - Characteristics– Motor development, always on the moveMotor development, always on the move– Language developmentLanguage development– Child begins to stray from motherChild begins to stray from mother– Child can be asked certain questionsChild can be asked certain questions– Accidents prevailAccidents prevail

• Ages 1-3 yrs - Common problemsAges 1-3 yrs - Common problems– Auto accidentsAuto accidents– Vomiting and diarrheaVomiting and diarrhea– Febrile seizuresFebrile seizures– Croup, meningitisCroup, meningitis– Foreign body obstructionForeign body obstruction



• Ages 1-3 yrs - ApproachAges 1-3 yrs - Approach– Cautious approach to gain confidenceCautious approach to gain confidence– Child may resist physical examChild may resist physical exam– Avoid “no” answersAvoid “no” answers– Tell the child if something will hurtTell the child if something will hurt


• Ages 3-5 years - CharacteristicsAges 3-5 years - Characteristics– Tremendous increase in motor developmentTremendous increase in motor development– Language is almost perfect but patients may not Language is almost perfect but patients may not

wish to talkwish to talk– Afraid of monsters, strangers; fear of mutilationAfraid of monsters, strangers; fear of mutilation– Look to parent for comfort and protectionLook to parent for comfort and protection


• Ages 3-5 yrs - Common problemsAges 3-5 yrs - Common problems– Croup, asthma, epiglottitisCroup, asthma, epiglottitis– Ingestions, foreign bodiesIngestions, foreign bodies– Auto accidents, burnsAuto accidents, burns– Child abuseChild abuse– DrowningDrowning– Meningitis, febrile seizuresMeningitis, febrile seizures


• Ages 3-5 yrs - ApproachAges 3-5 yrs - Approach– Interview child first, have parents fill in gapsInterview child first, have parents fill in gaps– Use doll or stuffed animal to assist in Use doll or stuffed animal to assist in

assessmentassessment– Allow child to hold & use equipmentAllow child to hold & use equipment– Allow them to sit on your lapAllow them to sit on your lap– Always explain what you are going to doAlways explain what you are going to do


• Ages 6-12 years - CharacteristicsAges 6-12 years - Characteristics– Active and carefreeActive and carefree– Great growth, clumsinessGreat growth, clumsiness– Personality changesPersonality changes– Strive for their parent’s attentionStrive for their parent’s attention

• Common problemsCommon problems– DrowningDrowning– Auto accidents, bicycle accidentsAuto accidents, bicycle accidents– Fractures, falls, sporting injuriesFractures, falls, sporting injuries


• Age 6-12 yrs - approachAge 6-12 yrs - approach– Interview the child firstInterview the child first– Protect their privacyProtect their privacy– Be honest and tell them what is wrongBe honest and tell them what is wrong– They may cover up information if they were They may cover up information if they were

disobeyingdisobeying


• Ages 12-15 - CharacteristicsAges 12-15 - Characteristics– Varied developmentVaried development– Concerned with body image and very Concerned with body image and very

independentindependent– Peers are highly important, as is interest in Peers are highly important, as is interest in

opposite sexopposite sex


• Ages 12-15 - Common problemsAges 12-15 - Common problems– MononucleosisMononucleosis– Auto accidents, sports injuriesAuto accidents, sports injuries– AsthmaAsthma– Drug and alcohol abuseDrug and alcohol abuse– Sexual abuse, pregnancySexual abuse, pregnancy– Suicide gesturesSuicide gestures

• Ages 12-15 - ApproachAges 12-15 - Approach– Interview the child away from parentInterview the child away from parent– Pay attention to what they are Pay attention to what they are notnot saying saying



• Characteristics of Parents response to Characteristics of Parents response to emergencies emergencies – Expect a grief reactionExpect a grief reaction– Initial guilt, fear, anger, denial, shock and loss Initial guilt, fear, anger, denial, shock and loss

of controlof control– Behavior likely to change during course of Behavior likely to change during course of

emergencyemergency


• Parent ManagementParent Management– Tell them your name and qualificationsTell them your name and qualifications

– Acknowledge their fears and concernsAcknowledge their fears and concerns

– Reassure them it is all right to feel as they doReassure them it is all right to feel as they do

– Redirect their energies - help you care for childRedirect their energies - help you care for child

– Remain calm and in controlRemain calm and in control

– Keep them informed as to what you are doingKeep them informed as to what you are doing

– Don’t “talk down” to parentsDon’t “talk down” to parents

– Assure parents that everything is being doneAssure parents that everything is being done

General Approach to Pediatric Assessment

• HistoryHistory– Be direct and specific with childBe direct and specific with child– Focus on observed behaviorFocus on observed behavior– Focus on what child and parents sayFocus on what child and parents say– Approach child gently, encourage cooperationApproach child gently, encourage cooperation– Get down to visual level of childGet down to visual level of child– Use a soft voice and simple wordsUse a soft voice and simple words

• Avoid touching painful areas until Avoid touching painful areas until confidence has been gainedconfidence has been gained

• Begin exam without instrumentsBegin exam without instruments

• Allow child to determine order of exam if Allow child to determine order of exam if practicalpractical

• Use the same format as adult physical examUse the same format as adult physical exam

Physical Exam


• Physical Exam (Physical Exam (cont.cont.))– Special concernsSpecial concerns

• Fontanels should be inspected in infantsFontanels should be inspected in infants– Normal fontanels should be level with surface of the skull Normal fontanels should be level with surface of the skull

or slightly sunken and it may pulsateor slightly sunken and it may pulsate– Abnormal fontanels Abnormal fontanels

• Tight and bulging (increased ICP from trauma or Tight and bulging (increased ICP from trauma or meningitis)meningitis)

• Diminished or absent pulsationDiminished or absent pulsation

• Sunken if dehydratedSunken if dehydrated


• Special concerns (Special concerns (cont.cont..).)– GI ProblemsGI Problems

• Disturbances are commonDisturbances are common

• Determine number of episodes of vomiting, amount Determine number of episodes of vomiting, amount and color of emesisand color of emesis

Pediatric Vital Signs

• Blood PressureBlood Pressure– Use right size cuff, one that is two-thirds the Use right size cuff, one that is two-thirds the

width of the upper armwidth of the upper arm

• PulsePulse– Brachial, carotid or radial depending on childBrachial, carotid or radial depending on child– Monitor for 30 secondsMonitor for 30 seconds

Pediatric Vital Signs• RespirationsRespirations

– Observe the rate before the child starts to cryObserve the rate before the child starts to cry– Upper limit is 40 minus child’s ageUpper limit is 40 minus child’s age– Identify respiratory patternIdentify respiratory pattern– Look for retractions, nasal flaring, paradoxical Look for retractions, nasal flaring, paradoxical

chest movementchest movement

• Level of consciousnessLevel of consciousness– Observe and recordObserve and record

Noninvasive Monitoring

• Prepare the child before using devicesPrepare the child before using devices– Explain the deviceExplain the device– Show the display and lights Show the display and lights – Let child hear noises if devices makes themLet child hear noises if devices makes them

• Pulse oximetry-particularly useful since so Pulse oximetry-particularly useful since so many childhood emergencies are many childhood emergencies are respiratoryrespiratory

Pediatric Trauma• BasicsBasics

– Trauma is leading cause of death in childrenTrauma is leading cause of death in children– Most common mechanisms-MVA, burns, drowning, Most common mechanisms-MVA, burns, drowning,

falls, and firearmsfalls, and firearms– Most commonly injured body areas-head, trunk, Most commonly injured body areas-head, trunk,

extremitiesextremities– Steps much like those in adult traumaSteps much like those in adult trauma

• Complete ABCDE’s of primary assessmentComplete ABCDE’s of primary assessment• Correct life threatening conditionsCorrect life threatening conditions• Proceed to secondary assessmentProceed to secondary assessment

Causes of Death

• NationalNational– MVAMVA 43%43%

– BurnsBurns 14.9%14.9%

– DrowningDrowning 14.6%14.6%

– AspirationAspiration 3.4%3.4%

– FirearmsFirearms3.0%3.0%

– FallsFalls 2.0%2.0%

• OklahomaOklahoma– MVAMVA 35%35%

– DrowningDrowning 14.5%14.5%

– BurnsBurns 14.0%14.0%

– FirearmsFirearms9.9%9.9%

– AspirationAspiration 5.7%5.7%

– Stab/cutStab/cut ??

Frequency of Injured Body Parts

• HeadHead 48%48%

• ExtremitiesExtremities 32%32%

• AbdomenAbdomen 11%11%

• ChestChest 9%9%

Pediatric Trauma

• Head, face, and neck injuriesHead, face, and neck injuries– Children prone to head injuriesChildren prone to head injuries– Be alert for signs of child abuseBe alert for signs of child abuse– Facial injuries common secondary to fallsFacial injuries common secondary to falls– Always assume a spinal injury with head injuryAlways assume a spinal injury with head injury

Pediatric Trauma

• Chest and abdominal injuriesChest and abdominal injuries– Second most common cause of pediatric trauma Second most common cause of pediatric trauma

deathsdeaths– Most result from blunt traumaMost result from blunt trauma– Spleen is most commonly injured organSpleen is most commonly injured organ– Treat aggressively for shock in blunt abdominal Treat aggressively for shock in blunt abdominal

injuryinjury

Pediatric Trauma

• Extremity injuriesExtremity injuries– Usually limited to fractures and lacerationsUsually limited to fractures and lacerations– Most fractures are incomplete - bend, buckle,, Most fractures are incomplete - bend, buckle,,

and greenstick fracturesand greenstick fractures– Watch for growth plate injuriesWatch for growth plate injuries

Pediatric Trauma

• BurnsBurns– Second leading cause of pediatric deathsSecond leading cause of pediatric deaths– Scald burns are most commonScald burns are most common– Rule of nine is different for childrenRule of nine is different for children

• Each leg worth 13.5%Each leg worth 13.5%

• Head worth 18%Head worth 18%

Pediatric Trauma

• Child abuse and neglect - BasicsChild abuse and neglect - Basics– Suspect if injuries inconsistent with historySuspect if injuries inconsistent with history– Children at greater risk often seen as “special” Children at greater risk often seen as “special”

and differentand different• Premature or twinsPremature or twins

• HandicappedHandicapped

• Uncommunicative (autistic)Uncommunicative (autistic)

• Boys or child of the “wrong” sexBoys or child of the “wrong” sex

Pediatric Trauma

• Child abuse and neglect - The child abuserChild abuse and neglect - The child abuser– Usually a parent or someone in the role of Usually a parent or someone in the role of

parentparent– Usually spends much time with childUsually spends much time with child– Usually abused as a childUsually abused as a child

Pediatric Trauma• Sexual Abuse - BasicsSexual Abuse - Basics

– Can occur at any ageCan occur at any age

– Abuser is usually someone in familyAbuser is usually someone in family

– Can be someone the child trustsCan be someone the child trusts

– Stepchildren or adopted children at higher riskStepchildren or adopted children at higher risk

• Paramedic actionsParamedic actions– Examine genitalia for serious injury onlyExamine genitalia for serious injury only

– Avoid touching the child or disturbing clothingAvoid touching the child or disturbing clothing

– Provide caring supportProvide caring support

Pediatric Trauma

• Triggers to high index of suspicion for child Triggers to high index of suspicion for child neglectneglect– Extreme malnutritionExtreme malnutrition– Multiple insect bitesMultiple insect bites– Long-standing skin infectionsLong-standing skin infections– Extreme lack of cleanlinessExtreme lack of cleanliness

Pediatric Trauma• Triggers to high index of suspicion for child Triggers to high index of suspicion for child

abuseabuse– Obvious fracture in child under 2 yrs oldObvious fracture in child under 2 yrs old– Injuries in various stages of healingInjuries in various stages of healing– More injuries than usually seen in children of same More injuries than usually seen in children of same

ageage– Injuries scattered on many areas of bodyInjuries scattered on many areas of body– Bruises that suggest intentional inflictionBruises that suggest intentional infliction– Increased ICP in infantIncreased ICP in infant

Pediatric Trauma

• Triggers to high index of suspicion for child abuse Triggers to high index of suspicion for child abuse ((cont.cont.))– Suspected intra-abdominal trauma in childSuspected intra-abdominal trauma in child

– Injuries inconsistent with historyInjuries inconsistent with history

– Parent’s account vague or changes during interviewParent’s account vague or changes during interview

– Accusations that child injured himself intentionallyAccusations that child injured himself intentionally

– Delay in seeking helpDelay in seeking help

– Child dresses inappropriately for situationChild dresses inappropriately for situation

Pediatric Trauma• Management of potentially abused childManagement of potentially abused child

– Treat all injuries appropriatelyTreat all injuries appropriately

– Protect the child from further abuseProtect the child from further abuse

– Notify the proper authoritiesNotify the proper authorities

– Be objective while gaining information Be objective while gaining information

– Be supportive and nonjudgmental of parentsBe supportive and nonjudgmental of parents

– Don’t allow abuser to transport child to hospitalDon’t allow abuser to transport child to hospital

– Inform ED staff of suspicions of child abuseInform ED staff of suspicions of child abuse

– Document completely and thoroughlyDocument completely and thoroughly

Pediatric Medical Emergencies - Neurological

• Pediatric seizures - Common causesPediatric seizures - Common causes– Fever, infectionsFever, infections

– HypoxiaHypoxia

– Idiopathic epilepsyIdiopathic epilepsy

– Electrolyte disturbancesElectrolyte disturbances

– Head traumaHead trauma

– HypoglycemiaHypoglycemia

– Toxic ingestion or exposureToxic ingestion or exposure

– Tumors or CNS malformationsTumors or CNS malformations


• Febrile SeizuresFebrile Seizures– Result from a sudden increase in body temperatureResult from a sudden increase in body temperature

– Most common between 6 months and 6 yearsMost common between 6 months and 6 years

– Related to rate of increase, not degree of feverRelated to rate of increase, not degree of fever

– Recent onset of cold or fever often reportedRecent onset of cold or fever often reported

– Patients must be transported to hospitalPatients must be transported to hospital


• AssessmentAssessment– Temperature - suspect febrile seizure if temp over 103 Temperature - suspect febrile seizure if temp over 103

degrees Fdegrees F

– History of seizureHistory of seizure

– Description of seizure activityDescription of seizure activity

– Position and condition of child when foundPosition and condition of child when found

– Head injury, RespirationsHead injury, Respirations

– History of diabetes, family historyHistory of diabetes, family history

– Signs of dehydrationSigns of dehydration


• Management - Basic StepsManagement - Basic Steps– Protect seizing childProtect seizing child– Manage the ABC’s, provide supplemental Manage the ABC’s, provide supplemental

oxygenoxygen– Remove excess layers of clothingRemove excess layers of clothing– IV of NS or LR TKO rateIV of NS or LR TKO rate– Transport all seizure patients, support the Transport all seizure patients, support the

parentsparents


• Management - If status epilepticusManagement - If status epilepticus– IV of NS or LR TKO rateIV of NS or LR TKO rate– Perform a Dextrostix <80 mg/dl give D25 2 Perform a Dextrostix <80 mg/dl give D25 2

ml/kg IV/IO if child is less than 12ml/kg IV/IO if child is less than 12– 12 or older give D50 1ml/kg IV12 or older give D50 1ml/kg IV– Contact Medical Control if long transportContact Medical Control if long transport


• Meningitis - BasicsMeningitis - Basics– Infection of the meningesInfection of the meninges– Can result from virus or bacteriaCan result from virus or bacteria– More common in children than in adultsMore common in children than in adults– Infection can be fatal if unrecognized and Infection can be fatal if unrecognized and

untreateduntreated

Meningitis

• AssessmentAssessment– History of recent illnessHistory of recent illness– Headache, stiff neckHeadache, stiff neck– Child appears very illChild appears very ill– Bulging fontanelles in infantsBulging fontanelles in infants– Extreme discomfort in movementExtreme discomfort in movement

• ManagementManagement– Monitor ABC’s and vital signsMonitor ABC’s and vital signs– High flow O2, prepare to assist with ventilationsHigh flow O2, prepare to assist with ventilations– IV/IO of LR or NSIV/IO of LR or NS– Fluid bolus of 20 ml/kg IV/IO pushFluid bolus of 20 ml/kg IV/IO push

• Repeat if no improvementRepeat if no improvement

– Orotracheal intubation if child's condition Orotracheal intubation if child's condition warrantswarrants

Meningitis


• Reye’s syndrome - BasicsReye’s syndrome - Basics– ““New” disease - Correlated with ASA useNew” disease - Correlated with ASA use

– Peak incident in patients between 5-15 yearsPeak incident in patients between 5-15 years

– Frequency higher in winterFrequency higher in winter

– Higher frequency in suburban and rural populationHigher frequency in suburban and rural population

– No single etiology identifiedNo single etiology identified• Possibly toxic or metabolic problemPossibly toxic or metabolic problem

• Tends to occur during influenza B outbreaksTends to occur during influenza B outbreaks

• Associated with chicken pox virusAssociated with chicken pox virus

• Correlation with use of aspirin use in childrenCorrelation with use of aspirin use in children


• Reye’s syndrome - ComplicationsReye’s syndrome - Complications– Respiratory failureRespiratory failure– Cardiac arrhythmiasCardiac arrhythmias– Acute pancreatitisAcute pancreatitis

• Assessment - Reyes SyndromeAssessment - Reyes Syndrome– Severe nausea & vomitingSevere nausea & vomiting

– Hyperactivity or combative behaviorHyperactivity or combative behavior

– Personality changes, irrational behaviorPersonality changes, irrational behavior

– Progression of restlessness, stupor, convulsions, comaProgression of restlessness, stupor, convulsions, coma

– Recent history of chicken pox in 10-20% of casesRecent history of chicken pox in 10-20% of cases

– Recent upper respiratory infections or gastroenteritisRecent upper respiratory infections or gastroenteritis

– Rapid deep respirations, may be irregularRapid deep respirations, may be irregular

– Pupils dilated & sluggishPupils dilated & sluggish

– Signs of increased ICPSigns of increased ICP


• Reye’s syndrome - ManagementReye’s syndrome - Management– General and supportiveGeneral and supportive– Maintain ABC’sMaintain ABC’s– Administer supplemental oxygenAdminister supplemental oxygen– Rapid transportRapid transport


Child’s Airway vs.. Adults

• Smaller septum & nasal bridge is flat and flexibleSmaller septum & nasal bridge is flat and flexible

• Vocal cords located at C3-4 versus C5-6 in adultsVocal cords located at C3-4 versus C5-6 in adults

– Contributes to aspiration if neck is hyperextendedContributes to aspiration if neck is hyperextended

• Narrowest at cricoid ring instead of vocal cordsNarrowest at cricoid ring instead of vocal cords

• Airway diameter is 4 mm vs.. 20 mm in adultAirway diameter is 4 mm vs.. 20 mm in adult

• Tracheal rings more elastic & cartilaginous, can easily Tracheal rings more elastic & cartilaginous, can easily crimp off tracheacrimp off trachea

• More smooth muscle , makes airway more reactive or More smooth muscle , makes airway more reactive or sensitive to foreign substancessensitive to foreign substances

5 Most Common Respiratory Emergencies

• AsthmaAsthma

• BronchiolitisBronchiolitis

• CroupCroup

• EpiglotitisEpiglotitis

• Foreign bodiesForeign bodies

Asthma

• PathophysiologyPathophysiology– Chronic recurrent lower airway disease with episodic Chronic recurrent lower airway disease with episodic

attacks of bronchial constrictionattacks of bronchial constriction• Precipitating factors include exercise, psychological stress, Precipitating factors include exercise, psychological stress,

respiratory infections, and changes in weather & temperaturerespiratory infections, and changes in weather & temperature

• Occurs commonly during preschool years, but also presents as Occurs commonly during preschool years, but also presents as young as 1 year of ageyoung as 1 year of age

– Decrease size of child’s airway due to edema & mucus Decrease size of child’s airway due to edema & mucus leads to further compromiseleads to further compromise

• Assessment Assessment – HistoryHistory

• When was last attack & how severe was itWhen was last attack & how severe was it

• FeverFever

• Medications, treatments administeredMedications, treatments administered

– Physical ExamPhysical Exam• SOB, shallow, irregular respirations, increased or decreased SOB, shallow, irregular respirations, increased or decreased

respiratory raterespiratory rate

• Pale, mottled, cyanotic, cherry red lipsPale, mottled, cyanotic, cherry red lips

• Restless & scaredRestless & scared

• Inspiratory & expiratory wheezing, rhonchiInspiratory & expiratory wheezing, rhonchi

• Tripod positionTripod position

Asthma

• ManagementManagement– Assess & monitor ABC’sAssess & monitor ABC’s

– Big O’s (Humidified if possible)Big O’s (Humidified if possible)

– IV of LR or NS at a TKO rateIV of LR or NS at a TKO rate

– Assist with prescribed medicationsAssist with prescribed medications

– Prepare for vomitingPrepare for vomiting

– Pulse oximeter Pulse oximeter

– Intubate if airway management becomes difficult or Intubate if airway management becomes difficult or failsfails

Asthma

• BasicsBasics– Respiratory infection of the bronchiolesRespiratory infection of the bronchioles– Occurs in early childhood (younger than 1 yr)Occurs in early childhood (younger than 1 yr)– Caused by viral infectionCaused by viral infection

• Assessment/HistoryAssessment/History– Length of illness or feverLength of illness or fever– has infant been seen by a doctorhas infant been seen by a doctor– Taking any medicationsTaking any medications– Any previous asthma attacks or other allergy problemsAny previous asthma attacks or other allergy problems– How much fluid has the child been drinkingHow much fluid has the child been drinking

Bronchiolitis

Bronchiolitis

• Signs & symptomsSigns & symptoms– Acute respiratory distressAcute respiratory distress

– TachypneaTachypnea

– May have intercostal and suprasternal retractionsMay have intercostal and suprasternal retractions

– CyanosisCyanosis

– Fever & dry coughFever & dry cough

– May have wheezes - inspiratory & expiratoryMay have wheezes - inspiratory & expiratory

– Confused & anxious mental statusConfused & anxious mental status

– Possible dehydrationPossible dehydration

Bronchiolitis

• ManagementManagement– Assess & maintain airwayAssess & maintain airway– When appropriate let child pick POCWhen appropriate let child pick POC– Clear nasal passages if necessaryClear nasal passages if necessary– Prepare to assist with ventilationsPrepare to assist with ventilations– IV LR or NS TKO rateIV LR or NS TKO rate– Intubate if airway management becomes Intubate if airway management becomes

difficult or failsdifficult or fails

• BasicsBasics– Upper respiratory viral infectionUpper respiratory viral infection

– Occurs mostly among ages 6 months to 3 yearsOccurs mostly among ages 6 months to 3 years

– More prevalent in fall and springMore prevalent in fall and spring

– Edema develops, narrowing the airway lumenEdema develops, narrowing the airway lumen

– Severe cases may result in complete obstructionSevere cases may result in complete obstruction

Croup

• Assessment/HistoryAssessment/History– What treatment or meds have been given?What treatment or meds have been given?

– How effective?How effective?

– Any difficulty swallowing?Any difficulty swallowing?

– Drooling present?Drooling present?

– Has the child been ill?Has the child been ill?

– What symptoms are present & how have they changed?What symptoms are present & how have they changed?

Croup

• Physical examPhysical exam– Tachycardia, tachypneaTachycardia, tachypnea

– Skin color - pale, cyanotic, mottledSkin color - pale, cyanotic, mottled

– Decrease in activity or LOCDecrease in activity or LOC

– FeverFever

– Breath sounds - wheezing, diminished breath soundsBreath sounds - wheezing, diminished breath sounds

– Stridor, barking cough, hoarse cry or voiceStridor, barking cough, hoarse cry or voice

Croup


– High flow humidified O2; blow by if child won’t High flow humidified O2; blow by if child won’t tolerate masktolerate mask

– Limit exam/handling to avoid agitationLimit exam/handling to avoid agitation

– Be prepared for respiratory arrest, assist ventilations Be prepared for respiratory arrest, assist ventilations and perform CPR as neededand perform CPR as needed

– Do not place instruments in mouth or throatDo not place instruments in mouth or throat

– Rapid transportRapid transport

Croup

• BasicsBasics– Bacterial infection and inflammation of the epiglottisBacterial infection and inflammation of the epiglottis

– Usually occurs in children 3-6 years of ageUsually occurs in children 3-6 years of age

– Can occur in infants, older children, & adultsCan occur in infants, older children, & adults

– Swelling may cause complete airway obstructionSwelling may cause complete airway obstruction

– True medical emergencyTrue medical emergency

Epiglotitis

• Assessment/HistoryAssessment/History– When did child become ill?When did child become ill?

– Has it suddenly worsened after a couple of days or Has it suddenly worsened after a couple of days or hours?hours?

– Sore throat?Sore throat?

– Will child swallow liquids or saliva?Will child swallow liquids or saliva?

– Is drooling present?Is drooling present?

– High fever (102-103 degrees F)High fever (102-103 degrees F)

– Onset is usually suddenOnset is usually sudden

Epiglotitis

• Signs & SymptomsSigns & Symptoms– May be sitting in Tripod positionMay be sitting in Tripod position

– May be holding mouth open, with tongue protrudingMay be holding mouth open, with tongue protruding

– Muffled or hoarse cryMuffled or hoarse cry

– Inspiratory stridorInspiratory stridor

– Tachycardia, tachypneaTachycardia, tachypnea

– Pale, mottled, cyanotic skinPale, mottled, cyanotic skin

– Anxious, focused on breathing, lethargicAnxious, focused on breathing, lethargic

– Very sore throatVery sore throat

– Nasal flaringNasal flaring

– Look very sick with high feverLook very sick with high fever

Epiglotitis


– Do not make child lie downDo not make child lie down

– Do not manipulate airwayDo not manipulate airway

– High flow humidified O2; blow by if child won’t tolerate High flow humidified O2; blow by if child won’t tolerate mask mask

– Limit exam/handling to avoid agitationLimit exam/handling to avoid agitation

– Be prepared for respiratory arrest, assist ventilations and Be prepared for respiratory arrest, assist ventilations and perform CPR as neededperform CPR as needed

– Contact medical controlContact medical control

Epiglotitis

• BasicsBasics– Common among the 1-3 age group who like to Common among the 1-3 age group who like to

put everything in their mouthsput everything in their mouths– Running or falling with objects in mouthRunning or falling with objects in mouth– Inadequate chewing capabilitiesInadequate chewing capabilities– Common items - gum, hot dogs, grapes and Common items - gum, hot dogs, grapes and

peanutspeanuts

Aspirated Foreign Body

• AssessmentAssessment– Complete obstruction will present as apneaComplete obstruction will present as apnea– Partial obstruction may present as labored Partial obstruction may present as labored

breathing, retractions, and cyanosisbreathing, retractions, and cyanosis– Objects can lodge in the lower or upper airways Objects can lodge in the lower or upper airways

depending on sizedepending on size– Object may act as one-way valve allowing air Object may act as one-way valve allowing air

in, but not outin, but not out


• Management - Complete ObstructionManagement - Complete Obstruction– Attempt to clear using BLS techniquesAttempt to clear using BLS techniques– Attempt removal with direct laryngoscopy and Attempt removal with direct laryngoscopy and

Magill forcepsMagill forceps– Cricothyrotomy may be indicatedCricothyrotomy may be indicated


• Management - Partial obstructionManagement - Partial obstruction– Make child comfortableMake child comfortable– Administer humidified oxygenAdminister humidified oxygen– Encourage child to coughEncourage child to cough– Have intubation equipment availableHave intubation equipment available– Transport to hospital for removal with Transport to hospital for removal with

bronchoscopebronchoscope


• HistoryHistory– Previous seizures, when it began, how longPrevious seizures, when it began, how long– Reason for seizureReason for seizure– When were fluids last taken, how much, is it usual for the When were fluids last taken, how much, is it usual for the

childchild– Current fever or medical illnessCurrent fever or medical illness– Behavior during seizureBehavior during seizure– Last wet diaperLast wet diaper– Any vomiting or diarrheaAny vomiting or diarrhea– Other medical problemsOther medical problems

Mild, Moderate, & Severe Dehydration

• Physical Assessment/Signs & symptomsPhysical Assessment/Signs & symptoms– Onset very abruptOnset very abrupt

– Sudden jerking of entire body, tenseness, then Sudden jerking of entire body, tenseness, then relaxationrelaxation

– LOC or confusionLOC or confusion

– Sudden jerking of one body partSudden jerking of one body part

– Lip smacking, eye blinking, staringLip smacking, eye blinking, staring

– Sleeping following seizureSleeping following seizure


• Physical Assessment/ Vital signsPhysical Assessment/ Vital signs– Capillary refillCapillary refill– Skin colorSkin color– Alertness, activity levelAlertness, activity level


• Mild dehydrationMild dehydration– Infants lose up to 5% of their body weightInfants lose up to 5% of their body weight– Child lose up to 3-4% of their body weightChild lose up to 3-4% of their body weight– Physical signs of dehydration are barely visablePhysical signs of dehydration are barely visable


• Moderate DehydrationModerate Dehydration– Infants lose up to 10% of their body weightInfants lose up to 10% of their body weight– Children lose up to 6-8% of their body weightChildren lose up to 6-8% of their body weight– Poor skin color & turgor, dry mucous Poor skin color & turgor, dry mucous

membranes, decreased urine output & increased membranes, decreased urine output & increased thirst, no tearsthirst, no tears


• Severe DehydrationSevere Dehydration– Infants lose up to 15% of their body weightInfants lose up to 15% of their body weight– Child lose up to 10-13% of their body weightChild lose up to 10-13% of their body weight– Danger of life-threatening hypovolemic shockDanger of life-threatening hypovolemic shock


• ManagementManagement– If mild or moderateIf mild or moderate

• Give fluids orally if there is no abdominal pain, Give fluids orally if there is no abdominal pain, vomiting or diarrhea and is alertvomiting or diarrhea and is alert

– SevereSevere• High flow O2High flow O2

• IV/IO with NS or LRIV/IO with NS or LR

• Fluid bolus of 20 ml/kg IV/IO pushFluid bolus of 20 ml/kg IV/IO push

• Repeat fluid bolus if no improvementRepeat fluid bolus if no improvement


Congenital Heart Disease

• Blood is permitted to mix in the 2 Blood is permitted to mix in the 2 circulatory pathwayscirculatory pathways– Primary cause of heart disease in childrenPrimary cause of heart disease in children– Various structures may be defectiveVarious structures may be defective– Hypoxemia usually resultsHypoxemia usually results

• HistoryHistory– Name of defect to share with medical controlName of defect to share with medical control

– Any meds taken routinely, were they taken todayAny meds taken routinely, were they taken today

– Any other home therapies (O2, feeding devices)Any other home therapies (O2, feeding devices)

– Any recent illness or stressAny recent illness or stress

– Child's colorChild's color

– What kind of spell, how long did it lastWhat kind of spell, how long did it last

– Ant treatment givenAnt treatment given


• Signs & symptomsSigns & symptoms– Intercostal retractions, difficulty breathing, tachypnea, Intercostal retractions, difficulty breathing, tachypnea,

crackles or wheezing on auscultationcrackles or wheezing on auscultation– Tachycardia, cyanosis with some defectsTachycardia, cyanosis with some defects– Altered LOC, limpness of extremities, drowsinessAltered LOC, limpness of extremities, drowsiness– Cool moist skin, cyanosis, pallorCool moist skin, cyanosis, pallor– Tires easily, irritable if disturbed, underdeveloped for ageTires easily, irritable if disturbed, underdeveloped for age– Uncontrollable crying, irritabilityUncontrollable crying, irritability– Severe breathing difficulty, progressive cyanosisSevere breathing difficulty, progressive cyanosis– Loss of consciousness, seizure, cardiac arrestLoss of consciousness, seizure, cardiac arrest


• ManagementManagement– Monitor ABC’s & vitalsMonitor ABC’s & vitals

– Maintain airway/administer high flow O2Maintain airway/administer high flow O2

– Assist ventilations as needed, intubate if neededAssist ventilations as needed, intubate if needed

– Cyanotic spell, place in knee chest positionCyanotic spell, place in knee chest position

– Prepare to perform CPRPrepare to perform CPR

– Establish IV TKO if lengthy transport time is Establish IV TKO if lengthy transport time is anticipatedanticipated


Home High Technology Equipment

• Chronic & terminal illnessChronic & terminal illness– Respiratory & cardiacRespiratory & cardiac

• Premature infantsPremature infants

• Cystic FibrosisCystic Fibrosis

• Heart defects & post transplant patientsHeart defects & post transplant patients

• VentilatorsVentilators

• SuctionSuction

• OxygenOxygen

• Tracheostomy Tracheostomy

• IV pumpsIV pumps

• Feeding pumpsFeeding pumps


• ManagementManagement– Support efforts of parentsSupport efforts of parents– Home equipment malfunction, attach child to Home equipment malfunction, attach child to

yoursyours– Monitor ABC’s & treat as patient’s condition Monitor ABC’s & treat as patient’s condition

warrantswarrants– Have hospital notify child’s physician if Have hospital notify child’s physician if

possiblepossible


PEDIATRIC EMERGENCIES. Pediatric Emergencies Basic Approach to Pediatric EmergenciesBasic Approach...

Documents

Transcript of PEDIATRIC EMERGENCIES. Pediatric Emergencies Basic Approach to Pediatric EmergenciesBasic Approach...